The pubovaginal sling has gained widespread acceptance in the surgical management of stress urinary incontinence. The surgical procedure has undergone several modifications in an attempt to improve clinical outcomes including modifying the sling material to include, in whole or in part, synthetic, homologous, autologous, or porcine materials; altering the location of the suspension anchor among suprapubic, retropubic, and bone locations; and modifying the surgical position of the sling.
It is apparent that a very delicate balance exists between urinary incontinence and retention, regardless of the sling material employed or the location of the sling suspension. Indeed, the primary factor to predict clinical success is related to the sling tension at the mid-urethra/bladder neck/sphincteric mechanism. If the tension of the pubovaginal sling is too loose, incontinence persists. If the sling is too tight at the bladder neck, urinary retention will develop. Previous attempts to regulate sling tension have not proven successful and the recommendation for sling tension is for surgeons to utilize “clinical judgment”. However, once the surgeon sets the tension during surgery, the tension cannot be adjusted after the surgery is completed.
In addition, recent data suggests that after an extended period of time, the suspension suture is indeed redundant because of the perivesical fibrosis that anchors the bladder into its fixed, high retropubic position. Moreover, the sling itself serves as a matrix for fibroblast deposition, which strengthens and supports the anterior vaginal wall.
Furthermore, since urinary incontinence is not a life threatening condition, many patients are expressing concern and reluctance about conventional procedures that employ materials harvested from cadaveric, bovine and porcine sources.